Jail / "Correctional Medicine"

[Atomec]

Anyone here work at a jail? A recruiter emailed me about what sounds like a very cushy part time position. Frankly I am a little surprised since the gig seems bettered suited for family medicine to manage chronic issues. Anyone have any first hand experience?

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[The Knife & Gun Club]

Our residency has a jail moonlighting clinic that functions much like an urgent care/primary care. I haven’t picked up shifts there yet, but speaking to the people who have some seem to enjoy it and some hate it. We pick up shifts along with FM and IM attendings and residents.

Interesting aspects include:
- compliance is very high. You have virtually a 0% no show rate for your clinic, if you tell someone to take their lisinopril with breakfast and check their BP 3x per day the jail will make sure it gets done. The patients can’t run off and no show for 3 months or doctor shop. The guards just go get the patient when it’s time for clinic.
- some interesting cases. Years of neglect and bad decision making before incarceration can lead to some neat pathology. Lac repairs.
- medical-legally the setup can vary but we have sovereign immunity which is nice. Just do what’s right for the patient.
- no metrics. You just show up, see your patients and walkin/urgent care type stuff, and leave. Virtually no admin.
- secondary gain problem is way higher than the ER. Patients will fake symptoms for a myriad of reasons for even innocuous things. They can figure out how to get high on medications that aren’t classically abusable. Years of ER visits have taught patients with bad intentions exactly what to say to get a work up, get a pass for the bottom bunk, or lube for their “dry skin.”
- overall the primary care aspect is def more suited to FM, but the seeing through the BS and determining who’s actually sick and needs transfer to ED for a work up and who doesn’t is more suited to EM. I’ve had co-residents catch stemis, surgical abdomens, and other badness in the jail clinic.

Again I’ve yet to work shifts there but it’s an interesting concept and probably a nice change of pace for the right person.

 

[wholeheartedly]

There’s a doc who wrote a book about this

Maximum Insecurity
A Doctor in the Supermax

by William Wright MD

read it awhile ago, can’t remember what I thought about it

 

[thegenius]

Anyone here work at a jail? A recruiter emailed me about what sounds like a very cushy part time position. Frankly I am a little surprised since the gig seems bettered suited for family medicine to manage chronic issues. Anyone have any first hand experience?

My experience are the jail docs send all things to the ER that can be remotely considered an emergency. Basically their decision making is on the same level as telephone advice nurses, which has an extremely low threshold to send everything to the ER.

So...maybe it is a cush job.

 

[Vandalia]

Our residency has a jail moonlighting clinic that functions much like an urgent care/primary care. I haven’t picked up shifts there yet, but speaking to the people who have some seem to enjoy it and some hate it. We pick up shifts along with FM and IM attendings and residents.

Interesting aspects include:
- compliance is very high. You have virtually a 0% no show rate for your clinic, if you tell someone to take their lisinopril with breakfast and check their BP 3x per day the jail will make sure it gets done. The patients can’t run off and no show for 3 months or doctor shop. The guards just go get the patient when it’s time for clinic.
- some interesting cases. Years of neglect and bad decision making before incarceration can lead to some neat pathology. Lac repairs.
- medical-legally the setup can vary but we have sovereign immunity which is nice. Just do what’s right for the patient.
- no metrics. You just show up, see your patients and walkin/urgent care type stuff, and leave. Virtually no admin.
- secondary gain problem is way higher than the ER. Patients will fake symptoms for a myriad of reasons for even innocuous things. They can figure out how to get high on medications that aren’t classically abusable. Years of ER visits have taught patients with bad intentions exactly what to say to get a work up, get a pass for the bottom bunk, or lube for their “dry skin.”
- overall the primary care aspect is def more suited to FM, but the seeing through the BS and determining who’s actually sick and needs transfer to ED for a work up and who doesn’t is more suited to EM. I’ve had co-residents catch stemis, surgical abdomens, and other badness in the jail clinic.

Again I’ve yet to work shifts there but it’s an interesting concept and probably a nice change of pace for the right person.

I would not necessarily agree with two aspects:

First, "compliance is very high" would perhaps be true in the rare, well-run, facility. However, what tends to happen is that inmates will not be brought to your clinic for days/weeks/months due to "staffing" or "security" concerns. Or as an example they will not be able to provide monitoring or insulin doses due to "security concerns." The fundamental rule is that security will trump everything else. Or, administrators will be concerned about cost and cap everything else. I also saw cases where the administration would interfere with prescriptions, "Sorry, the supplier was out of lisinopril and it would have cost too much so we substituted ibuprofen for a couple of months." These are actual cases.

Second, there is not necessarily "sovereign immunity" for malpractice claims. @The Knife & Gun Club very will may be associated with a place that provides it, but it is usually the exception. As a recent opinion said, "Only a Sovereign has sovereign immunity." That means it only applies to the state and federal government. So if you work for a county or city facility it does not have any type of sovereign immunity. In addition, with the exception of perhaps California or New York, most medical care has been passed off to contractors, who also do not have sovereign immunity. Finally, if you are involved in correctional healthcare, you WILL be sued - A LOT - in the form of "individual capacity" civil rights (1983) suits. It is one of their favorite hobbies. While it is tough to meet the "deliberate indifference" standard, it can happen. The problem is that things you do not have direct control over can get you into trouble.

Indiana: Williams v. Ind. Dep't of Corr.

This is not to say it is worthwhile or not, but the reality of correctional medicine very often does not match the way things should be in theory. A third-grade understanding of the geography of American politics should make it clear where this is more or less true.

 

[d2305]

There's a lot of HIV and TB in prison which you have to manage.

 

[Birdstrike]

I once took care of a family member of a doc who did jail medicine, when I still worked in the ED. He told me, "It's the best kept secret in Medicine."

 

[Kryptocoin]

Prison medicine is great...if you never want to work in the private industry again. Inmates sue a lot. You'll be hard to credential if you decide to get out. I remember there was an old thread on SDN from a jail doc that get sues 5x/year. The State will handle the cases on your behalf but you'll still be named.

 

[RuralEDDoc]

Prison medicine is great...if you never want to work in the private industry again. Inmates sue a lot. You'll be hard to credential if you decide to get out. I remember there was an old thread on SDN from a jail doc that get sues 5x/year. The State will handle the cases on your behalf but you'll still be named.

Echo that. Seeing prisoners or prison guards hurt by prisoners is a nightmare a year or two later when you get subpoenaed.

 

[DeadCactus]

Apparently there is a whole fellowship now.

Correctional Medicine Curriculum

Overview for the Correctional Medicine curriculum.

osteopathic.nova.edu

 

[bravotwozero]

In sum, don’t do it. Crap pay and high liability, with a not nice patient population.

 

[Angry Birds]

In sum, don’t do it. Crap pay and high liability, with a not nice patient population.

I can only imagine that there is at least some psychological impact of spending so much time in such an environment.

 

[sah]

In California the prison system recruits mostly board certified Internal Medicine or Family Practice, not Emergency Trained. Benefits for those are very good though the pension formula is much less now for new to the state system. Salaries at most complex prisons are $340 to $358k salary plus additional benefits of $83k per year benefits.
Inmates for the most part are not the hard part of working in the system. The system is very hard to manage. “Paperwork” for a simple 5minutes office visit for HTN follow up visit can run 45minutes to fill out all the “other” administrative forms. You also get about 5 federal lawsuits per year which are annoying.

you can see the benefits:

Physician Careers

Physician Careers with California Correctional Health Care Services, Apply With Us

cchcs.ca.gov

 

[medsurf83]

Just finished my first week. Im a contractor doing locums for the prison. Locums can make a killing here with hourly rate .
My take:
Its safe for providers. Inmates are extremely grateful to us.
They can be manipulative and as said about try to get you to put them off work or on bottom bunk. Its easy to spot a liar.
No "quality metrics/ admin meetings bs"
Amazing pathology... i saw testicular torsion, lots of.hep c cases in one week.
Great schedule. No set time to arrive or leave work generally. I can show up at 9-10am as long as i see the patients.

 

[BoardingDoc]

Locums can make a killing here with hourly rate

Define killing. To be clear, I'm not making a joke about this being prison medicine and this being a reference to murder. I want to know what the rate is.

 

[medsurf83]

Define killing. To be clear, I'm not making a joke about this being prison medicine and this being a reference to murder. I want to know what the rate is.

140/hr plus 150 perdiem. Forcme, thats a high hourly rate coming from occ med

 

[timpview]

My buddy ended up in an online expose about prison abuse and poor prison care (inmate death)… even though he had nothing to do with it… then the lawsuit followed. But the public shame was pretty intense.

 

[medsurf83]

Oh and forgot to mention its 4 day work week. I ask for monday off. You basically work as much or little as you want... im in texas btw may be different elsewhere

 

[BoardingDoc]

140/hr plus 150 perdiem. Forcme, thats a high hourly rate coming from occ med

Got it. Thanks for the info. From an EM point of view, that rate is extremely low. The intensity of the work appears to be commensurately low as well, but that would be a peri-retirement gig for most EPs I would imagine.

 

[DeadCactus]

140/hr plus 150 perdiem. Forcme, thats a high hourly rate coming from occ med

Out of curiosity, are you coming from Occ Med through the residency trained/board certified route? Are you a physician? I'm a little surprised to hear $140/hr as "making a killing".

 

[sah]

In California you need board cert in IM or Family for most positions. When hourly rate factored in with vacation time off, it is closer to $200/hr for prisons with complex medical inmates. Pensions were previously a strong benefit though with reform, much less attractive for new hires now. Main downside is 5 new civil rights (not malpractice) lawsuits per year on average. They almost always fail but tie you up timewise.

 

[medsurf83]

Out of curiosity, are you coming from Occ Med through the residency trained/board certified route? Are you a physician? I'm a little surprised to hear $140/hr as "making a killing".

Yes and yes. Most i ever made orior to this is 130 an hr diing oem.. Its just part time until i find a good occ med gig.. sure rate is lower than em but the workload and stress is 10x lower ..

 

[The Knife & Gun Club]

I started with the corrections clinic I mentioned above about 14 months ago and honestly it’s been a great experience.

150/hr is their per Diem rate so by EM standards it’s not great but the acuity and mental/task load is not even close. I can do the shifts in my sleep. I can do them after overnights.

Make one clinical decision/dispo at a time, with patients who are under 24/7 supervision for decompensation and legally protected by sovereign immunity.

My list is usually 16 patients per 12hr shift but a handful will decide not to come, or are just there for a simple reason like following up on some normal imaging or labs I ordered a week prior. It’s a great gig. My brain would probably rot doing it full time though, the acuity is mind-numbingly low even compared with an urgent care.

 

[DeadCactus]

Yes and yes. Most i ever made orior to this is 130 an hr diing oem.. Its just part time until i find a good occ med gig.. sure rate is lower than em but the workload and stress is 10x lower ..

Got ya, thank for the reply. I always hear rumours of OEM people making bank with the right industry job so I was a little surprised to hear $140/hr be so remarkable. Admittedly, I have no idea how true or common those rumours are.

 

[medsurf83]

Got ya, thank for the reply. I always hear rumours of OEM people making bank with the right industry job so I was a little surprised to hear $140/hr be so remarkable. Admittedly, I have no idea how true or common those rumours are.

In occ med you either go corporate medicine (ie work for facebook, exxon, ibm, ford) or clinic. I chose clinic. My last hospital job i made 285 which isnt bad. We have low burnout too which is nice!

 

[DeadCactus]

In occ med you either go corporate medicine (ie work for facebook, exxon, ibm, ford) or clinic. I chose clinic. My last hospital job i made 285 which isnt bad. We have low burnout too which is nice!

Any insight into what the corporate world is like? Again, thanks for responding to a random strangers inquisition.

 

[RustedFox]

In occ med you either go corporate medicine (ie work for facebook, exxon, ibm, ford) or clinic. I chose clinic. My last hospital job i made 285 which isnt bad. We have low burnout too which is nice!

285... what?

 

[Apollyon]

285... what?

I'm guessing 285k/yr

 

[JacobMcCandles]

285... what?

285k dollhairs.

 

[RustedFox]

I'm guessing 285k/yr

Eh. For the low cognitive load.... I can see the trade off.
I would want "X" days off in a month, and that number has to be 10+.

 

[Little drop of rain]

Best, decision, ever, made.

That said, individual experience varies from jail to prison, from private to public, all different sorts of facilities. In the end it’s all about what works for you and your family. All I can say is to give it a try before turning it down.

 

[sylvanthus]

May not be a bad coast-to-retirement gig.

 

[The Knife & Gun Club]

May not be a bad coast-to-retirement gig.

That’s my current plan is to stay on/credentialed for per Diem and do 1-2/month indefinitely.

At least the system I work for I literally say any hours I want and they’re granted so can easily fit the shifts into my schedule, usually with 1-2 weeks notice.

Want to do a 3p-3a on a Tuesday night? Or a 7a-2p on a Saturday? I pick a time and they bring the patients.

It’s kind of like a bit of a “diversified income” fallback plan, because I can ramp up to 160 clinical hours a week at any moment in case I have a sudden loss in my main salary.

 

[Janders]

Back years ago we had a solid ED RN who was getting her NP. And doing it, as best she could, the right way. Arranged good rotations with people that would teach, constantly had questions about pathology, meds, etc (while working as an RN).

When she finished she approached about getting an NP job with our group in the ED (we historically have been 100% PA, never an NP). I told her the hard truth as someone that had worked bedside with her for years, and did like her on a friendly basis as well— she wasn’t ready to fly in a busy ED with minimal teaching and moderate supervision. But that I would certainly recommend her to a job that was potentially more appropriate for her stage.

She ended up getting a prison job (and still worked perdiem EDRN shifts, so we chatted about it a bit) and LOVED it. It had moderate acuity at times, some sick/late stage things would show up, fair amount of trauma, tons of suturing, but also some classic PCP-style work and ED/UC things (acute belly pain, acute chest pain). Where she worked she had a supportive supervising physician who was happy to have her bounce things off him when he was off site. But the PACE was not high. 1pph style UC/clinic. And as a state job I think her benefits were excellent.

Anyway, pot-for-every-lid type position.

 

[WorkNoteEmergency]

The two big industries in my rural ED cachement area are nursing homes and prisons. Probably about 6 prisons feed into our 17 bed ED, hard to keep track of them and there is one that is even combo nursing home/prison. I generally enjoy the interactions with prisoners and would say that turd-like behavior is about the same, maybe even slightly better than the general ED population. It seems prisoners get bounced around a lot, so not uncommon to get one with complex medical issues with scanty medical records popping in for the first time. Also a lot of head injuries from “fell out of my bunk”.

Funny reading the earlier posts in the thread describing prison medicine and I thought “dang I’d say the same thing about Navy medicine”

 

[Angler]

maybe even slightly better than the general ED population.

Yeah, in my many years of practice, I took care of a handful of patients from jail/prison, including one on death row. All were well behaved and very appreciative of the care I gave. Way nicer than the many patients I had who felt very entitled.

 

[Apollyon]

Yeah, in my many years of practice, I took care of a handful of patients from jail/prison, including one on death row. All were well behaved and very appreciative of the care I gave. Way nicer than the many patients I had who felt very entitled.

Same for me, but, I never wanted to know for what they were convicted, because it would possibly color my perspective. One guard told me, if they're really old guys, they're either molesters or mob guys. One paramedic thought it was funny saying what was the crime. It was an agency that didn't usually come to us. I told him I didn't want to know. He thought I was joking. I don't know why he thought that.